Why NHS 'Friends & Family test' is weak measure of patient experience

Putting the patient and their experience at the heart of healthcare improvement is now firmly established as a principle. This includes a recognition that patient narratives and stories of their experience of living with health conditions is a valid and valuable way of gathering insight for and measuring improvement.
But when is the right time to capture patient narratives? And how narrowly should their experience be framed?

Since 2013, NHS patients in England have been asked to complete a Friends and Family Test (FFT), responding to the 'simple' question "whether they would recommend hospital wards, accident and emergency units to a friend or relative based on their treatment?" The Dept of Health's guidance suggest that "patients should be surveyed on the day of discharge or within 48 hours of discharge. This will ensure that the answer given reflects the patient's informed opinion, based on recent experience."

But this approach creates problems. For example, if patients are being asked about the NHS experience by the people providing it, it is hardly an independent method of assessment. And if patients believe they are likely to return to hospital, (esp. common among older patients) there may well be a positive skew of scoring, for fear of retribution or reprisal, or a wish not to be critical, face-to-face, for fear of confrontation. (Source: Roy Lilley -NHS writer and broadcaster)

The latest FFT statistics for November 2017 show typical recommendation endorsement above 90 per cent. But from our studies of patient research, we have a fear that this Friends and Family Test misrepresents the patient experience. Our research experience across 9 years finds that patient assessment of their experience is more complete and insightful when conducted in retrospect, looking back over a number of weeks, months or even years.

Why is this so? We cite a number of reasons:

The majority of patients we have studied have required follow up appointments, checks and tests, esp. for those with chronic conditions. These follow up events are an integrated part of the overall patient experience, and should be included together with any initial treatment

By narrowing the question to the specific "treatment" of the condition they are being admitted for, this may not capture how patients experience their overall care (surgery may be "treatment" but is a bed bath, or the quality of food?). Our research shows that patients typically assess experience of hospitals holistically, and that by using the term "treatment', many aspects may be omitted

By requiring an assessment within 48 hours, this can make it very hard for patients to include consideration of whether their treatment was successful or not. For example, how can the treatment of a wound infection be assessed within such a timeframe?

Furthermore, there is alarming evidence from the USA that nearly one in five elderly patients discharged from hospital will be re-admitted within 30 days with a completely different ailment from the one that originally landed them in a hospital bed, according to a report published by the New England Journal of Medicine. How do the FFT figures reflect 'regular patients' and its impact on the scores?

Our takeout:

The Friends and Family Test should not be seen as a wholly negative development, as some commentators have suggested. After all, it will provide near real-time data of patient scores, comparable across different hospitals.

However, we do not feel it offers any real depth of insight into how patients themselves assess the total experience of being treated by the NHS. Furthermore, the timeframe of 48 hours is fundamentally flawed, and may even skew results to misrepresent the patient experience.

We firmly believe that studies using retrospective patient interviews offers participants the chance to describe healthcare in their own words, and across a timeframe which includes patient views of successful and holistic outcomes. From our LifelinesTM studies of people living with chronic conditions, we frequently hear patients and their carers describe their hospital treatment experiences. Patients often talk of how they have seen others being treated in the same ward, or how their discharge procedure was handled. Such narratives hold rich insight for how NHS Trusts can improve their care and positively impact patient outcomes. We strongly hope that a simple NPS-style 'Friends and Family' summary question will not distract from the valuable detail held within patient stories.